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First Name
Last Name
Company Name
Address
City
State Zip Code
Country  
Telephone Fax
E-Mail
Job or REQ#
Required Pump Capacity
GPM Total Head
(Feet)		 NPSH-A (FT)
Chemical Composition
Viscosity Specific
Gravity 		Boiling
Point
Pumping
Temperature 		System Suction (Pressure)
Static Head (FT) Will Chemical Crystallize?
Description of Solids
Motor Requirements
HP RPM Voltage(s)
  Phase HZ
Motor Enclosure
Horizontal Pump
  Seal: Single Double
    Dynamic Double
Packing with Lantern
Discharge Fitting FNPT:  
FF FL :  
 

Close-Coupled
Pump OK:

Frame Mounted
Pump Req.
 

Base

Coupling / Guard
 

Casing Drain

Casing Vent

Vertical Pump
Sump Depth and Size

Mounting Plate
Mat'l
Discharge
Location
Discharge Fitting FNPT: Shaft Seal at Mnting. Plate
FF FL :
Float Controls XP Switch:  
Mech Alt
Pump to be Mounted In Sump  
Dry Mount
   
 

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